Update: OHIP+ Children and Youth Pharmacare

We try and stay informed of the changes that happen within the Ontario Ministry of Health and share that information when it becomes available.  Most employees and their dependent children are having claims paid at the pharmacy with no problem, but from time to time they may come to you with questions and below are some links that may prove helpful.

March 16, 2018

We are pleased to share this update on OHIP+: Children and Youth Pharmacare (OHIP+) with you.

As the weekly webinars have now ended, the ministry will continue to provide updates through eblasts to ensure individuals receive the information they need regarding OHIP+.

If you have any questions or comments, please feel free to contact the ministry at OHIPplus@ontario.ca.


As of March 16, 2018, there have been more than 2.5 million OHIP+ paid claims processed. This includes antibiotics to treat infections, inhalers for asthma, various insulins, oral diabetic medications and diabetes test strips, epinephrine auto-injectors (e.g. EPIPENs®), and drugs to treat arthritis, epilepsy and other chronic conditions.


If an OHIP+ recipient needs a drug not listed on the Ontario Drug Benefit (ODB) Formulary, they may be able to get the drug covered under the Exceptional Access Program (EAP).

To see if a drug is available through the EAP, please visit the following website:  www.ontario.ca/page/check-medication-coverage/

To view a list of EAP medications please see the attached DIN list or visit:http://www.health.gov.on.ca/en/pro/programs/drugs/eap_criteria.aspx

For more information on the EAP, visit https://www.ontario.ca/page/applying-exceptional-access-program#section-0

Check the online eFormulary for LU drugs and criteria: https://www.formulary.health.gov.on.ca/formulary/ 

For information on EAP reimbursement criteria of frequently requested drugs including biologics, please visit: http://www.health.gov.on.ca/en/pro/programs/drugs/docs/frequently_requested_drugs.pdf).

Visit us online at www.ontario.ca/OHIPplus

Prescription Drug Checker Tool: www.ontario.ca/page/check-medication-coverage/


Ontario Employers – Are You in Compliance?

Employers with employees in Ontario often ask us to confirm legislative requirements under various employment statutes, including mandatory postings, training, and policies under the Employment Standards Act, 2000, the Occupational Health and Safety Act, and the Accessibility for Ontarians with Disabilities Act. To make this information conveniently available, the Littler Toronto office has assembled these requirements in a single publication, which was originally disseminated in August 2017. An updated version of this publication can now be accessed through the link below.

Ontario Mandatory Postings

National pharmacare strategy to preserve existing system: Morneau

No one is exactly sure what the recent budget announcement will mean, but I’m guessing that employee benefit plans are NOT going to be dropping their drug plans anytime soon.  Both the Kirby and Romanow Reports, of 15 years ago, pointed to improving prescription drug coverage, but little if anything has progressed on a national level.  Maybe this time?

Finance Minister Bill Morneau says the national pharmacare committee assembled this week will preserve the best parts of Canada’s existing drug plans, rather than abandon them in pursuit of a new, country-wide universal program.

Editorial: Projections for drug costs a mixed bag for plan sponsors

Our clients have seen average OVERALL benefit plan rate increases (including all benefits, not just drugs) of less than 4.5% over the past 15 years.  2017 brought some higher increases averaging 7.5% (partly due to aging) but according to the article below, we may see the rate of increase slow again over the coming year.

According to projections released by Aon Hewitt in December, costs for extended health-care plans will likely rise by six per cent in 2018. After inflation of 2.1 per cent, the net projected cost increase is 3.9 per cent. That’s down measurably from an overall cost increase of eight per cent in 2017 and a net rise of 6.1 per cent. And the numbers compare well to the global gross cost increase of 8.4 per cent.  For Article CLICK HERE

Seminar to help staff navigate prescription drug claim issue

My association (Canadian Group Insurance Brokers – CGIB.CA) is holding a seminar for brokers, insurers and employers on Wednesday February 28th from 8 am until noon in Vaughan.  Tickets are $175 but FREE to Mainstay clients.  We have a limited number of seats available, so if you are interested in attending, please send me an e-mail before THIS Friday at 5pm to hold a spot.  Details are below…

Employees are asking employers questions when; a claim is not paid, a generic drugs is substituted for brand, Prior Authorization questions are asked, there are delays in dispensing their drugs, or they are told that drugs will only be paid for and dispensed by certain pharmacies.

Clients are often faced with an employee that says “you can’t make me take these pills, or tell me where to shop”. We’ll help provide you with the right answer to share that will help to deal with those conversations quickly and efficiently.  The presentations also cover; navigating the “system” to help support staff, identifying tools that are available to assist employees, as well as patient support programs that can improve health outcomes.

Information and directions are below.  But let us know if you’re interested, and we’ll book a spot at no charge to you.


Brokers group hits out at insurers over compensation guideline

Proposed guidelines on compensation disclosure in group benefits has received short shrift from a national brokers group. Members of the Canadian Group Insurance Brokers (CGIB) claim the Canadian Life and Health Insurance Association’s (CLHIA) consultation process has neglected their views. Earlier this month, CLHIA head Stephen Frank announced that Guideline G19 – Compensation Disclosure in Group Benefits and Group Retirement Services – would be held back until January 1, 2019. This, he explained, would provide insurers more time to properly engage with advisors and brokers. According to CGIB head Dave Patriarche, however, this isn’t the case, and brokers have been largely left out of any real decision making.

Have a youth that has a drug claim declined?

We have had some feedback from clients (very few) that their employees with dependent children age 24 and under are having issues with the new OHIP+ program.  This issue is caused when someone under age 25 is using what is called an EAP drug.  In the past, these drugs would normally be covered by the private employer benefit plan. The province is now covering this with OHIP+ as of January 1st, 2018.  This means that the private plans will NOT pay for these drugs until the province has declined coverage.

There is more information on the provincial website link below, as well as the list of the over 1000 EAP Drug ID Numbers (DINS) that need special application forms completed…



A look at the five-year forecast for drug plan cost increases

Employers will see private drug plan costs rise by about six per cent annually over the next five years, according to a prediction by a health-care research company.

Brad Millson, principal of health access and outcomes at IQVIA, presented the results of his firm’s 2017-21 forecast, produced in partnership with Innovative Medicines Canada, at Benefits Canada’s 2017 Face-to-Face Drug Plan Management forum on Dec. 14.